Value Stream Management, Make Value Flow

The next important concept in a lean agency is making value flow to the client. Basically, this means the identification and elimination of barriers, delays, redundancies and any other waste. Beginning from the customer's perspective, the parties closest to the client examine all that they do and need in order to create value for the consumer. Are any steps taken unhelpful or counterproductive. If so those steps should be eliminated, unless they are required by compliance. In that case effort should be allocated towards changing the requirement.

The next step repeats the previous one with a new customer. Now, instead of the consumer, the direct care worker (DSP) is the customer and those who provide resources to the DSP evaluate their activities, eliminating any waste of time, treasure, effort or energy along the way to providing the DSP what he or she needs to provide value to the client. As above, some waste will be immediately correctible and some will be in service of robust statute, policy or regulation. Either way, that waste (called Type II waste) is as bad as the correctible (Type I) waste.

To make an agency lean, these step should be followed not only for the entire heirarchy at the agency, but as far back in the Value Stream as can be observed. At each step, the purpose is to eliminate wasted functions. As the process goes on, it will be mapped in terms of tasks, not jobs. At each step, the influences causing Type II waste should be recorded for the purpose of advocacy.

When this process is complete, all the Type I waste should be eliminated and value will flow more quickly and efficiently from the finding source to the client. It should be noted that in this system, real leanness will have to change regional centers and DDS as well as vendored agencies.

Here's an opinion. I suspect this system has an absurd amount of waste and that a ridiculous amount of it is of Type II.

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I received Spam as soon as I initially posted this. I don't like spam but haven't taken precautions against it because one option eliminates anonymous posting (although it allows a person to take a name not their own) and the other includes a verifier which could be hard for people with disabilities. How would you, dear readers feel about a requirement that you identify yourselves (as anyone or anything) in order to make a comment?

Value Stream Management, Identify the Value Stream

Apologies for my neglect of this site, now, where were we?

Once value is specified in terms of what the client wants, the next step in developing a lean system or organization is to identify the value stream. This refers to the sequence of actions that bring resources forward toward the end client. It includes everything the agency does, but also everything their suppliers do. In California's system, for example, the process of becoming lean would start with what the client needs and look at how the direct support staff provide for that. The next step would be to look at the both the program design and the supervisor and how each provide the needed resources for the direct support person to serve the customer.

Value Streams when looked at honestly are extraordinarily complex and long, and rarely confined within a single agency in manufacturing. Certainly not in this system. This does not mean by itself that they are wasteful or inefficient. The economist, Milton Friedman once used a cover photo on one of his books depicting himself holding a pencil. The point of the photo was the pencil which contained rubber from Indonesia, metal mined in Central America, wood from canada and graphite from somewhere else (it's been awhile since I read Friedman) and were assembled and sold in the United States for a dime apiece.

A rough example of a value stream might be as follows: A male Supported Living client is hungry so a staffperson cooks for him using food purchased by another staffperson with money delivered by a Supervisor. Those funds may have been given to the Supervisor by an agency comptroller who cashed a check with funds for several clients received from the regional center as the fiduciary for Social Security. On another branch of the Value Stream, the employee cooking was following a person-centered Individualized Service Plan (ISP) which authorized cooking and described any parameters to the meal. That ISP may have been reviewed by a supervisor and must have been also reviewed by a regional center employee, signed off on by a Program Manager and funded. Both the funds and the terms of approving the ISP were delivered to the regional center from DDS based on allocations and controlling statutes set forth by the California legislature. If the client was eligible for the Medicaid waiver, a second branch of the allocation and regulation process travels through the federal government.

There are three things that I believe can safely be said about the process above:
1) That it is an oversimplification of the value stream leading to a single client eating a single meal,
2) That it probably repeats tens of thousands of times per day in California, maybe a half-million times per year.
3) That it probably doesn't go smoothly every time at every step. Even 99% success reflects a lot of defects in a tiny portion of the overall community-based system.

Taken together, if the assertions above are true, there exists extraordinary potential for both improving the satisfaction of clients and reducing the cost of the system. Just in the preparation of meals. Just in Supported Living clients.

Note: Because demons have prevented me from updating this site regularly, I am adding a feed to the links. People interested in this site who have browsers with RSS capability can bookmark the link marked "Pay attention!" to be notified of updates.

Value Stream Management, Specify Value

The first step in Lean Thinking is to specify value: What will our whole process from the legislative appropriation through the client create, and what that should cost. At this step, original and comprehensive thinking are crucial. For example, in our system, we often treat the service provided as the outcome. I suspect that we think this way, because in our system, the service is, in fact, the last compensated part of the process. Sometimes assigning a value to the service doesn't seem like such a good idea in case someone compares the cost, but this is why we try to fix stuff.

I would suggest that in the system design, value is creatively and well described. We say that the system exists so that people with developmental disabilities can choose and experience lives similar to their non-disabled peers as fully integrated members of their community. To this we add health, safety and dignity at least in interactions with the participants in the system. This isn't very specific, but it is humane, measurable, creative and comprehensive. The current specification in statute of what that should cost is "whatever it takes" which may be unsettling to many taxpayers and politicians but it won't be me pushing for a hard number. It may be useful, however, that if Lean Thinking settles in that some rationale for costs may actually be useful in providing better lives to clients.

So we have three pieces of our value specification:
1. The outcome of the system is that people with developmental disabilities will live in a manner of their own choosing a life equivalent to that of a non-disabled peer as an integrated member of their community.
2. The client's experience of the system will be dignified, attentive and safe.
3. It will cost whatever necessary to meet the first two value propositions and no more.

That looks pretty specific to me, although we can debate how often those propositions are really carried out. I would contend that everywhere in this system that we are not conscientiously specifying value the implied value specification is this:
1. The outcome of the system is that people receive services of their choosing.
2. The client's experience with the system will comply with Regional Center policies and state regulations.
3. Costs will be in line with those incurred by other clients deemed similar.

So, I would say the system is relatively successful in specifying value but wholly unsuccessful in remembering or communicating the specification.

Value Stream Management, Introduction

This series of posts will propose a new concept of leanness from the one used currently in our system and outline a roadmap for getting there. This introduction will contrast the proposed definition to the one typically used and lay out the parts of the lean roadmap, which will make up the next five posts in this series.

The idea of leanness in a chronically underfunded system usually refers to underperformance. When we talk about how lean our agencies have become, we usually refer to things we feel we should be doing or be doing more of. My friends who run agencies might point out regulations they no longer comply with, a reduction in Quality Assurance activities, services that our clients need or want that they no longer offer, etc. The failure to perform key tasks is a predictable outcome of frozen rates and growing mandates, but it's better described with the word erosion than leanness.

I remember an old joke about the guy who lost 20 pounds of ugly fat when he was decapitated. That's a good metaphor for our concept of leanness. The usage in Lean Thinking refers to the elimination of waste. Waste can be found at three levels,
1. Activities and costs that do not actually generate value for our clients,
2. Activities and costs that could generate the same amount of value with less investment if done differently, and
3. Activities and costs for which there are substitutes that generate equal or greater value for clients with less investment.

I think most agencies serving California's people with developmental disabilities are about as eroded as they can be. I would argue that none, including the one I run, are as lean as they should be. Growing leaner is a process of increasingly and consistently directing dollars and energy into creating value for the people we serve.

So, the roadmap outlined by Womack and Jones follows the following process.

Part I: Specify Value, defining what needs are served;
Part II: Identify the Value Stream, recognize the contributors to the generation of the value specified;
Part III: Make the Value Stream flow, this step represents a radical reimagining of how work is best done with a focus on seeking and eliminating waste;
Part IV: Pull, which is a corporate analogy of person-centered support; and
Part V: Perfection, which institutionalizes a permanent and continuous process of improving steps I-IV.

So the next five posts in this planned nine-part series will look at each of the parts of Lean Thinking in the context of California's system of service and support for people with developmental disabilities.

New series of posts-Value Stream Management

Thanks to everyone who wished this site a happy birthday or blogiversary or whatever it was. The next series of posts, probably nine in all will discuss the benefits of Value Stream Management as a paradigm for reform of this system. The series will roughly follow James P. Womack and Daniel T. Jones' book Lean Thinking.

There are a few reasons that Value Stream Management (VSM) is an attractive model. The first is that the concept of "Let the customer pull value" is essentially a business-world equivalent of person-centered thinking. The second is that the paradigm defines efficiency in a way that I find much more engaging than the normal way that we discuss the idea in this field. Those of you who have known me for awhile know how pessimistic I am that our system will ever be fully funded to operate under the current structure. The real hope for a better system falls to redesign and reimagination. A third reason is that VSM promotes honesty and transparency regarding the possibility of doing things better.

A Disclosure: I am currently working with partners to develop an instrument for applying the concepts of Value Stream Management to our system. While I certainly honor objectivity, I should admit that I both have already made up my mind as to VSM's value and hope to profit from its application.

Bouncing baby blog

Happy first birthday, little Developmental Disability System Reform. You're number one on Google and number one in our hearts. Back to the mine!

Self-Directed Services: My endorsement

I support self-directed services (SDS) because in concept, SDS programs empower people with disabilities by removing some control from service providers (including both Regional Centers and direct service-providers,) because an effective SDS program lowers the cost of quality in services and supports by involving the person best able to control costs in the negotiation for price, and because without SDS the integration and sovereignty sought by the DDS system for people with disabilities are largely absent from its workings.

The current proposal adopted by the legislature's budget conference committee certainly will implement the initials SDS and may well lead to the actual manifestation of its meaning. The ban on using SDS while a client lives in a congregated facility or uses a day program certainly limits both the choice of clients and the benefit to the system and the state. The failure to specify the role of service coordination staff in SDS, which may or may not occur in writing the regulations, leaves up in the air how much actual control will pass to people with disabilities and, therefore, whether or not this new program meets its goals or produces significant benefits.

Fears as to whether the regulations being developed will follow the normal process of public input have placed many erstwhile supporters of SDS into a skeptical state.

All of that said, this proposal is the most promising reform to come this close to implementation. So, I endorse the SDS proposal with the anticipation that legislative and regulatory corrections will be needed to implement SDS itself.